Transradial approach: Do we have gain without excessive pain?

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Transradial approach: Do we have gain without excessive pain?

Address for Correspondence: Muhammad Tariq Farman, Jinnah Medical College Hospital C-45, Block-2, KAECHS; Karachi-Pakistan Phone: 0092-21-34545957 E-mail: tariqfarman@yahoo.com

DOI:10.5152/akd.2014.112014

Editorial Comment

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Transradial approach (TRA) was described over 60 years back, but it was not gained much attention due to equipment and technical limitations (1). Then it received new interest after the work of Campeau et al. (2) some 25 years back. After him, Kiemeneij et al. (3) introduced successful interventional proce-dures via radial approach. Since then, TRA has become popular in many parts of the world and many centers across the world has been adopting and developing transradial catheterization training programmes (4, 5).

Although TRA is being used more commonly due to increased convenience for the patient, early mobilization and decreased access site bleeding complications. However, concerns have been raised about increased radiation exposure and prolonged procedure time (6, 7). It is due to the fact that TRA is technically more demanding and bearing specific challenges in comparison with the transfemoral approach (TFA) (8). These include radial and subclavian artery anomalies, access failure, and radial artery spasm (RAS) (9). Among them RAS is the most common complication (9). This spasm often makes the procedure painful for the patient. Moreover, it results in difficulty in catheter manipulation and thus makes the procedure complexed, time consuming and sometimes may end up with procedure failure or crossover to TFA. The SPASM study shows that young and female are the independent predictors of RAS (10). Other studies show that the diameter of radial artery and diabetes mellitus are the predictors of RAS (11, 12).

In this March issue of Anatolian Journal of Cardiology pub-lished Aktürk et al. (13) reported the problem of RAS in the per-spective of pain levels. Author compared the pain levels of transradial and transfemoral coronary catheterization in a rea-sonably good number of patients. He assessed pain levels in a very well defined manner by using visual analogue scale (VAS). Aktürk et al. (13) reported that TRA group showed higher VAS scores than those in TFA group. It was further reported in his study that patients having BMI <24 kg/m2_{and/or wrist} circum-ference <16.7 cm predicted unacceptable pain.

It is indeed an interesting piece of information not only for interventional cardiologist but those who prefer to choose radial approach for various other interventions. In the above men-tioned study highly skilled operators approach radial artery under good sedation (Diazepam 7.5 mg PO) in addition to intrave-nous dose of nitroglycerine and verapamil. Even then they

encountered the problem of RAS in more than 21% of patents. This shows that with the current practice we cannot completely abolish this problem and until new techniques/equipments are freely available to avoid RAS we should be more selective while intervene the patients. This should not be the matter of ego for radialists. Being selective for radial or femoral approach keeping consideration various factors is a good and sensible strategy for patients as well as for operators. This selectivity is highly rec-ommended especially if someone is going to do complex inter-ventions where he may need unusual catheter manipulation. Selective approach saves the precious time of operators by decreasing procedure time. It also saves the time of busy cath-eterization laboratories by reducing occupancy and hence increases the number of procedures. It also helps reducing the radiation exposure that often considered trivial but in fact a wor-risome problem (14, 15).

Nature believes in diversity and hence in this way it main-tains the beauty and continuity in life. Variety is a blessing and it often gives us a way out from a trapped situation. Therefore better selection among the various options on the basis of sci-entific data is a wise approach and hampers us from various complications.

Tariq Farman

Department of Cardiology Jinnah Medical College Hospital; Karachi-Pakistan

References

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13. Aktürk E, Kurtoğlu E, Ermiş N, Açıkgöz N, Yağmur J, Altuntaş MS, et al. Comparision of pain levels of transradial versus transfemoral coronary catheterization: A prospective and randomized study. Anadolu Kardiyol Derg 2014; 14: 140-6.

14. Lange HW, Von Boetticher H. Randomized comparison of operator radiation exposure during coronary angiography and intervention by radial or angiography and intervention by radial or femoral approach. Catheter Cardiovasc Intervent 2006; 67: 12-6. [CrossRef]

15. Farman MT, Khan NU, Sial JA, Saghir T, Rizvi SNH, Zaman KS. Comparison of fluoroscopy time during coronary angiography and interventions by radial and femoral routes-can we decrease the fluoroscopy time with increased experience? An observational study. Anadolu Kardiyol Derg 2011; 11: 607-12.

Farman T.

Transradial approach Anadolu Kardiyol Derg 2014; 14: 147-8